The LPN provides a coordinated, strategic approach to detect and manage the health needs of chronically or mentally fragile patients. They act as a liaison between providers, patients, and families to ensure effective care plans and community resource navigation.
Requirements summary
Candidates must hold a current Michigan LPN license and possess previous experience in chronic disease patient care. Proficiency in health IT systems and strong communication skills are required for this role.
professional certificateCare coordinationClinical assessmentElectronic medical recordsPatient advocacyCase managementCare planningPatient communicationMedication managementBehavioral healthData reportingChronic disease managementHealth literacyCommunity resource mobilizationHealth IT systemsImmunization programming
Job description
Work Schedule
0800 to 16: 30 Monday through Friday at Hillsdale Hospital clinics
Education assistance & continuing education; many courses offered on-site at the hospital
Qualifications
1.
Current Michigan licensure as an LPN 2.
Previous experience in caring for chronic disease patients required 3.
Prefer experience in clinical or community health, care coordination, case management, home health or behavioral health 4.
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred 5.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers if needed 6.
Must be proficient in communication and computer technologies (email, cell phone, etc.) 7.
Previous experience with health IT systems, ERMs and data reports
Responsibilities
1.
Provides a coordinated, strategic approach to detect early and manage effectively the chronically and/or mentally fragile patient population.
2.
Utilizes tools and documents that support a guided care process, collaborating with patient/family toward an effective plan of care.
3.
Assesses patient and family’s unmet health and social needs 4.
Provides effective communications to improve health literacy for patients/families 5.
Coaches patients/families towards successful self-management of their chronic disease 6.
Acts as liaison between PCP and Specialists on patient condition as needed between office visits 7.
Develops a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan 8.
Benefits
Vacation
Holidays
Dental insurance
Vision insurance
Medical insurance
Paid time off
Prescription insurance
Life insurance
Disability insurance
Education assistance
Continuing education
403(b) retirement plan
Monitors patient adherence to plan of care and progress toward goals in a timely fashion, and facilitates changes as needed 9.
Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire 10.
Promotes healthy behaviors in all populations and ensures navigation assistance with community resources 11.
Assists in outreach to patients made after they have been seen in ED or inpatient stay as necessary.
12.
Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator) 13.
Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals 14.
Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
15.
Enrolls patient in Medicaid and assists with other community resource referrals when applicable.
16.
Ensures effective tracking of test results, medication management, and adherence to follow-up appointments 17.
Facilitates and attends meetings between patient, families, care team, payers, and community resources 18.
Ensures all VBR and MSSP metrics are met.
19.
Assists with VFC (Vaccines for Children) immunization programming at current Primary Care sites.
